Pathological Gambling and Substance Abuse

Transcription

1 Pathological Gambling and Substance Abuse H. Westley Clark, MD, JD, MPH, CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration President George W. Bush State of the Union January 28,2003 Addiction crowds out friendship, ambition, moral conviction, and reduces all the richness of life to a single destructive desire. Michael O. Leavitt 20th Secretary of the U.S. Department of Health and Human Services Demographics is destiny. And there is a time in the life of every problem when it is big enough to see but small enough to solve. Opening Statement before the United States Senate Finance Committee March 15, 2005 Charles G. Curie, M.A., A.C.S.W. Administrator Substance Abuse and Mental Health Services Administration People of all ages, with or at risk for mental or substance use disorders, should have the opportunity of a fulfilling life that includes a job, a home and meaningful relationships with family and friends. December, 2004 SAMHSA s Goals Accountability: establish systems to measure performance and ensure accountability Capacity: build, enhance and maintain treatment infrastructure and capacity Effectiveness: enable all communities and providers to deliver effective treatment services Promoting Accountability Enhancing Capacity Assuring Effectiveness 1

2 Casino revenues exploded in July Kansas City Star Kansas City s four boats brought in $60 million, shattering the previous monthly high of $57.9 million set in May. Missouri s 11 casinos banked a combined $131.5 million, surpassing the old record of $124.2, also reached in May. The difference so far.has been a steady flow of new casino amenities along with massive casino spending on advertising and promotions to attract new business The Kansas City Star, C-1,8, August 12, 2004 THEN SUPERINTENDENT STOLE FUNDS TO FEED GAMBLING HABIT Theft of $854,699 draws prison term, large crowd from tiny school district Away from the race tracks and plush Nevada betting rooms where he gambled away money meant for teachers salaries and supplies, former Pattonsburg school Superintendent Ronnie G. Deshon wept. Deshon pleaded guilty in March to federal program fraud, admitting that he took the money to feed his gambling addiction. The Kansas City Star, A-1, A-4, August 25, 2005 GAMBLE: Ex-schools chief gets 42 months Deshon estimated that he made 160 trips and carved out numerous four-day weekends to gamble at horse and dog tracks and wager in swank Las Vegas sports betting rooms where he said eh received red carpet treatment. They looked up to the man and trusted him, [Chris] Gannan said. Now, it s total distrust. The Kansas City Star, A-4, August 25, 2005 KC man charged in dice-game killing A gambling dispute prompted someone to shoot Gail W. Johnson in the back several years ago, relatives say. He survived. But a dispute in a dice game Tuesday proved fatal to Johnson, 36, according to Kansas City police. At Johnson s house, the three played two hands of dominoes, smoked crack cocaine and drank beer. Jackson then gave Johnson $20 to buy more crack and beer. Johnson returned with a small amount of crack and one beer which angered Jackson. Nonetheless, the three shared the crack and the beer and continued playing dominoes. Later the game was switched to dice. The Kansas City Star, B-3, August 25, 2005 Financial Times Regulators Fight to Control Online Gambling The popularity of televised poker has fuelled a boom in online gambling.us authorities consider online gambling illegal, but companies running it are based overseas, where US law does not apply. Most gambling websites accept bets from US punters.this proliferation of online gambling makes curbing the industry like emptying the ocean with a teaspoon, said one government insider. August 20, 2005 The Worst of All Bets Experts often describe pathological gambling as being both a pure and a hidden addiction. It is pure because it does not change the brain chemistry by introducing other substances like drugs or alcohol do. It is hidden because, unlike say, mainlining heroin, gambling is generally a socially acceptable behavior. Socially acceptable behavior run amok, that is. Source: US News and World Report. 5/23/05 2

3 In the News After Oklahoma s lottery is up and running and the state is collecting revenue from Indian gaming allowed at horse tracks, officials estimate the state will receive about $221 million annually in revenue. But the state is prepared to dedicate only $750,000 a year for treatment of those with gambling problems and preventative measures. Muskogeephoenix.com, August 17, 2005 Program Emphasizes Treatment, Not Incarceration, for Louisiana s Problem Gamblers The treatment program is a funded through the Department of Health and Hospitals Office of Addictive Disorders, Compulsive and Problem Gambling Fund, which receives revenue from the gambling industry as required by law. This program will keep nonviolent individuals out of our prison system and is actually more costeffective and preventive than mere incarceration. Source: Louisiana Department of Health and Hospitals; News Release, Jan. 7, 2005 Thousands Needed and Received Substance Abuse Treatment in the Past Year among Persons Aged 12 or Older by Gender, Needed Tx for Illicit Drug Numbers in Thousands Received Specialty TX Did Not Receive Specialty TX Office of Applied Studies (2004) Results from the 2003 National Household Survey on Drug Use and Health Male Female Thousands Needed and Received Substance Abuse Treatment in the Past Year among Persons Aged 12 or Older by Gender, Needed Tx for Alcohol Numbers in Thousands Received Specialty TX Did Not Receive Specialty TX Office of Applied Studies (2004) Results from the 2003 National Household Survey on Drug Use and Health Male Female Most Adults Who Needed Treatment for Substance Use Problems Did Not Feel A Need for Treatment, 2003 Received TX 16% 78% 6% Illicit Drugs Felt No Need for TX 7% 4% 89% Alcohol Felt Need for TX, but untreated 2003 NSDUH Gambling and Substance Use It is reasonable to conclude that not only will a rise in the opportunity to gamble for the general population result in a rise in the number of individuals seeking treatment for problem/pathological gambling, but the individuals who present for treatment of substance use disorder will be more likely to have a co-occurring compulsive gambling disorder. Source: Treatment for Pathological/Problem Gambling and the Role of State Alcohol and Other Drug Agencies. NASADAD, 12/2004 3

4 Gambling and Use of Methamphetamine The states are anecdotally reporting the use of methamphetamine by problem gamblers to stay awake, particularly in Casino Gambling. ~Anne Herron, Director, Division of State and Community Assistance, CSAT Problem or Pathological Gambling and Perceived Need for Treatment Problematic gambling is more common among people with alcohol use disorders compared with those without AUDs. A major problem for those concerned about problem or pathological gambling will be the perceived need for treatment by those who are affected by the condition. The prevalence of Pathological Gambling is influenced by both the availability of gambling and the duration of availability, With the increased availability of legalized gambling there is an increase in the prevalence of Pathological Gambling Gambling (continued) Pathological gambling resembles dependence on a physical substance, and symptoms are consistent with tolerance, withdrawal, relief use, preoccupation, efforts to control or discontinue, and significant social and occupational consequences. Signs of Problem Gambling People feel that they need to bet more money more frequently People feel irritated when they try to stop People think that they can chase their losses to recover money Persists in gambling despite financial losses and loss of trust of friends and loved ones Spend a large portion of their income on gambling Problem Gambling Gambling causes Emotional Family Legal Financial Or other problems for the gambler or the people around the gambler May get worse over time Ranges from mild to severe 4

5 Challenges in Treating Problem and Pathological Gambling Differences between gambling and substance abuse Gambling is not yet accepted as a true addiction In most cases, insurance will not pay for gambling treatment Most casinos offer free drinks and the effect of free alcohol on problem gambling is not well understood Challenges (continued) Screening is progressing faster than treatment capacity clinicians often do not know what to do about a positive screen Need exists for culturally competent services Need for advocacy groups to present their point to Legislators State Response to Gambling In 23 States, SSAs have responsibility for treatment of problem/pathological gambling In 22 States, substance abuse treatment providers receiving SSA funding offer problem/pathological gambling treatment services In 21 States, AOD treatment providers routinely screen for problem gambling In 13 States, AOD treatment providers routinely assess problem gambling In 11 States, AOD treatment providers routinely treat problem gamblers State Response to Gambling 7 SSAs identified other State Agencies responsible for the treatment of pathological gambling 17 of the 22 SSAs that have current responsibility for treatment also report existing funds to support it 8 SSAs identified anticipated funding State Response to Gambling Of the 25 SSAs that identified existing or anticipated special funding to support problem gambling prevention/treatment activities, 21 described revenue streams that are directly tied to gaming revenue. Reasons Why SAMHSA Should be Involved: Co-occurring Disorders: Gambling And- Alcohol abuse and dependence Drug abuse and dependence Including nicotine addiction Major depression Suicide: ideation, attempts, and completion 5

6 Needs of Special Populations Older adults a prevalence study of Florida residents found that almost 2 percent of older adults could be classified as lifetime pathological gamblers (Volberg 2003) College students In prevalence studies, community college students consistently demonstrate higher rates of gambling problems than adults Public school students There has been a significant increase in number of children and adolescents engaging in gambling. The popularity of the game Texas Holdem has contributed to this increase Federal Response to Problem Gambling Deferred to States National Council of Legislators from Gaming States Deferred to Non-Profit Organizations National Council on Problem Gambling Association of Problem Gambling Service Administrators National Gambling Impact Study Commission 1999 Establishing the Problem Not a part of our Household Survey Largest National Survey of Its kind Over 67,000 individuals interviewed face to face Source: State Experience in Addressing Problem Gambling. Aug Application of the National Registry of Effective Programs and Gambling In January of 2003, SAMHSA received the report, Problem Gambling Treatment and Prevention: Application of the National Registry of Effective Programs from Intersystems, Inc. A SAMHSA funded effort to identify model, effective or promising programs NREP PROBLEM GAMBLING PROGRAM TRIAGE Known Gambling Prevention and Treatment Programs (N 300) Programs Available for Review (N- 150) Invited and Submitted Programs (N-10) NREP PROBLEM GAMBLING PROGRAM TRIAGE Triaged (N = 10) Pyramid of Evidence-Based Practices No Program Documentation ( N= 3) Programs Reviewed (N= 4) Single-Blind Design (N= 2) Ineffective (N= 1) Promising Programs (N = 3) Programs Rated as Insufficient Current Support (N=3) Center for Substance Abuse Treatment. 2005a 6

7 SAMHSA Recognizes that Problem and Pathological Gambling is a Co- Occurring Problem Support for Midwest Conference on Problem Gambling and Substance Abuse August 11-13, 2004, Kansas City, MO Support for the International Symposium on Problem Gambling and Co-Occurring Disorders October 18-19, 2004 Mystic Marriott Hotel and Spa Mystic, Connecticut, USA Providing Services to Problem and Pathological Gamblers Through the Single State Authorities (SSAs) On June 25, 2004 SAMHSA s Center for Substance Abuse Treatment (CSAT) held a focus group meeting on: State Experiences in Addressing Problem Gambling Representatives from 9 jurisdictions in various states of evolution in gambling participated Providing Services to Problem and Pathological Gamblers Through the Single State Authorities (SSAs) (continued) June 17, 2005 CSAT held a meeting with representatives from State responsible for providing services for problem and pathological gambling to continue discussing the States experience in addressing problem gambling Representatives from 15 jurisdictions in various states of evolution in gambling participated CSAT Supports NASADAD Study for Treatment of Pathological/Problem Gambling and the Role of State and Other Drug Agencies 50 States and District of Columbia responded to study 23 respondents asserted their SSAs have responsibility for treatment of problem/pathological gambling 27 States and the District of Columbia responded in the negative. Future Directions Questions to Ask 7

8 Business Labor Who Has Jurisdiction for Providing Services to Those With Gambling Problems? Which State system is the most reasonable, and potentially most effective, choice to take responsibility for pathological gambling? View I: Separate State Service System View II: Substance Abuse Treatment System View III: Mental Health Delivery System How can gambling treatment programs be funded? How can programs be funded? SPMI? Other revenues? Are State legislative changes needed? Effective evidence-based practices What are the most effective ways to deal with the addiction and with the profound negative consequences of pathological gambling? Depression Suicide Child Neglect and abuse Loss of jobs Home foreclosure Domestic violence Impact on the elderly and other special populations Is there a Cost Benefit to Intervention? Providing services for pathological gamblers can save the State money across other systems, reducing costs in terms of the criminal justice system, child neglect and abuse, domestic violence and other systems. Child Welfare Faith Housing Education PREVENTION Primary Care Criminal & Juvenile Justice MENTAL HEALTH Promote Partnerships Create forums in which SAMHSA and private organizations can develop collaborative strategies to improve alcohol and drug treatment and recovery services Promote communication and collaboration among: States and communities Service providers Academic institutions Researchers People in Need of Treatment People in Recovery to provide an efficient, seamless system of services 8

9 Promote Partnerships Continue to expand partnerships with: Prevention Mental Health Primary healthcare providers Child welfare agencies Faith-based organizations Criminal justice system Schools Business Community Labor Community to enhance appropriate, quality service delivery in all health and human services Substance Abuse Treatment Capacity Strategic Prevention Framework Mental Health System Transformation Primary healthcare Child welfare Criminal & Juvenile justice system Education Business Labor Community & Faith-based organizations Gaming Industry Recommendations Assume a neutral stance Recognize the State s ethical responsibility Work with the gaming industry Learn from other states Be flexible in planning Enhance System Effectiveness Facilitate consensus on quality of care and treatment outcomes Support implementation of evidence-based practices that guide screening, intervention, assessment, engagement, individual and group therapies, relapse prevention, and continuing care Develop reimbursement mechanisms that: Incorporate performance requirements Ensure support for system reinvestment Facilitate consensus on the dynamic of Recovery Definition Components Agents Science to Service Connecting Services and Research Identifying Evidence-based Practices for Problem and Pathological Gambling Providing Technical Assistance for Treatment Providers to adopt evidence-based practices National Outcome Measurements (NOMs) Abstinence from Drug / Alcohol Use Employment / Education Crime and Criminal Justice Family and Living Conditions Access / Capacity Retention Social Connectedness Perception of Care Cost Effectiveness Use of Evidence-Based Practices Possible Gambling Outcome Measurements Abstinence Reduction in gambling activity Employment status Crime & Criminal Justice Bankruptcy/Financial Status Loss of home or business Family relationships and problems Retention in treatment Cost Effectiveness Use of Evidence-Based Practices 9

10 Develop the Workforce Conduct a nationwide addiction treatment and peer to peer workforce survey and develop a comprehensive report on the state of the workforce Establish national gambling addiction professional minimum competency standards Develop ongoing data collection of information about the changing characteristics of the workforce Continue dissemination of research findings and evidence-based clinical and organizational practices through the ATTC s and other mechanisms Develop Core Principles of Effective Treatment Place clients in level of care most appropriate for individual Use cognitive behavioral therapy as the preferred therapeutic approach Include motivational interviewing techniques Develop treatment designs that are specific to the clinical needs of problem gambling clients Include a family program component Reduce Stigma Promote stigma reduction for persons in treatment and recovery Respect their rights Treat recovering persons like those suffering from other illnesses Support educational initiatives that inform the public about the effectiveness of treatment Promote the dignity of persons in treatment and recovery Address Workforce Burnout As we develop strategies to recruit people into the workforce, we must develop strategies to keep people in the workforce. Career Ladders, Burnout Reduction, and Adequate Compensation are essential components of any comprehensive workforce strategy. SAMHSA/CSAT Information SHIN for publication ordering or information on funding opportunities TDD line HELP SAMHSA s National Helpline (average # of tx calls per mo.- 24,000) 10